36-201 (7) 39 WINTEREIERRY 4N 8P•20190281
COMMONWEALTH OF MASSACHUSETTS
A ,;36.201 CITY OF NORTHAMPTON
I,pj-QQI PERSONS CONTRACTING WITH UNREGISTERED CONTRACTORS
permit BUlldlna DO NOT HAVE ACCESS TO THE GUARANTY FUND (MGL e.142A)
CateeoNY INSULATION BUILDING PERMIT
Permit a BP-2019.1281
Proieat0 J9-2018.002073
Est Coat•53881.00
eqs.$6],20 PERMISSION IS HEREBY GRANTED TO:
"N"IMIL Contractor: License:
um w, JOSEPH GEORGE,_x,72
Lot Sine(sa. ft'); 82347.2Q Owns: W ILINSKY JOHN F
T. 29 WINTERBERRY
AaaikWidga a: eiwe: Insurance;
64 HaYWOOD ST (413) 774-3604 WC
GREENFIFLDMA01301 ISWPDD ON•5/112V 9 0:00:00
TO PERFORM THE FOLLOWING WORR:AIR SEAL ATTIC AND BASEMENT ADD 12" OF
CELLULOSE TO EXISTING INSULATION IN ATTIC
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Inspector of Plumbing Inspector aP Wiring A.P.W. Bu gigng Inspector
Undergrounds Services Meter;
Footings;
Troughs Rough: House Foundation:
priYeway FiRsh
Flools Pialh
Rough Frames
Gas; Nre/le°...r _.t FlreplaCelChlmpeY;
Roughs Insulation;
Finals Final;
Final;
THIS PERMIT MAY BE REVOKED BY THE CITY OF NORTHAMPTON UPON VIOLATION OF
ANY OF ITS RULES AND REGULATIONS.
rtifiWjt qf Qg;Upgn2j Signature:
FeeTXgej Date Paid; AMqunt:
Building 5/14(20140:00:00 $65.00
212 Main Street,Phone(413)587-1240,Fax:(414)587,1272
Louis Hasbrouck—Building Commissioner
City of Northam on R E C E I
Building Depa ant
212 Main Room 100 00a t MAY 1 3 7 '
Northampton, MA 010
phone413-587-1240Fax,41X597M N" 1 4
'.uaTr+a.*rioN.�n
APPLICATION FOR INSULATION FOR A ONE OR TWO FAMILY DWELLING ONLY
SECTION I -SITE INFORMATION INSULATION PERMIT ePw-1-2 fi
1.1 Property Address: This section to be carrlPleted by office- .
3� w*tirWj Lit t Map e Lot 0 / M -
PO(YAtf)1/^JA Zone Overlay District
010" L EIm3CAisMM C8'DieMeC
SECTION 2-PROPERTY OWNERSHIPIAUTHORIZED AGENT
21 Darner of Record:
GInJ� wd Nlly 39 `;`Atyrr�j Lw fbrence, A 014
Name(Pnrd) f^��jj.. r Current M ailing Addr x:11` -5j5'- 03\11
k
See hclkA Telephone Y JJ11
Signature
2.2 Authorized Apert:
Current Mailing ��Y�O� �!'• UR'kA�)Q1d �01}Q�
IL3] 7� 4-lboy
Signature Telephone
KCTION 3-ESTIMATED CONSTRUCTION COSTS
Item Estimated Cost(Dollars)to be Official Use Only
completed by permit applicant
1. Building 3, 1 Ij (a)Building Permit Fee
2. Electrical (b)Estimated Total Cost of
Construction from fi
3. Plumbing Building Permit Fee
4. Mechanical(HVAC)
5.Fire Protection V
S. Total=it +2+3+4+5) S h0- S Check Number
This Section For Official Use Only
Building Permit Num Date
Issued:
1 117
Signature:
Building Comcsesionedlnspector of Buildings Dale
EMAIL ADDRESS (REQUIRED; EITHER HOMEOWNER OR CONTRACTOR)
SECTION 4-CONSTRUCTION SERVICES
8.1 Licensed Construction Supervisor::/ Not Applicable ❑
Name of I-Ionse Holder:- ��.�� r�C,l ' qqbl
License Number
h4 H(nvwmJ St. Grtftj-, lit 1AA, 0130) a/II/A)
Address I Expiration Date
��V�A • (413) -119
Signature Telephone
9.1teotstered Homalmproyemant.Cerrtractor: . . Not Applirabk ❑
J-1 Gfo�g moll Sin Tnr. jlgA
Coracaury a Registration Number
I R(Agwnd S1. 7/as115
Address __. FViration Date
Telephone
13 ZD")dD
SECTION S-WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152,§2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result
in the denial of the issuance of the building permit.
Signed Affidavit Attached Yes....... ❑ No...... Ok
Brief Description of Proposed Work NOTE: INSULATION ONLY
A'Ir Seal 0)il- Wj 60krl¢M
Add P:' Of ce4wlose 10 QX01n) in otlx
I, 31as Owner,Authorized
Agent hereby declare that the statern and information on the foregoing application are true and accurate,to the best of my knowledge
and belief.
Signed under the pains and penalties of perjury.
3bsp .
Print Name
& rn ' wg/15
Signature of OwnertAgent13 Date
I, CgqilN�pl W(1,,1enas Owner of the subject
hereby
property t/��I\ yW'YL
hereby authorize
W act on my behalf,in all ma=w to work authorized by this building permit application.
See Ai3uLVI N(d4�14
Signature of Owner Date
City of Northampton _
Massachusetts
IISPAa19ENT OF BUILDING INSPECTIONS
212 Nei. ii r.t 1ffiuni.t,,1 suilding ♦ 1CD
a.rtaampt.n, NA. 01060
AFFIDAVIT
Home Improvement Contractor Law
Supplement to Permit Application
The Office of Consumer Affairs and Business Regulation("OCABR")regulates the registration of contractors and
subcontractors performing improvements or renovations on detached one to four family homes.Prior to
performing work on such homes,a contractor most be registered as a Home Improvement Contractor("HIC").
M.G.L.Chapter 142A requires that the"reconsbuctlon, alteration, renovation, repair, nrodemization, conversion,
improvement removal, demolition, or construction of an addition to any pre-existing owner occupied building containing
at least one but not more than four dwelling units....or to structures which are adjacent to such residence or building"be
done by registered contractors.
Note:If&e homeowner has contracted with a corporation or LLC,that endty must be registered.
Type of Work: TAJu�rklon Est.Cost: 3/00 I'm
Address of work: 39 4vli*rkj'j L4e hwiy) M A )010ti
Date of Permit Application:
I hereby certify that:
Registration is not required for the following reason(s):
_Work excluded by law(explain):
—Job under$1,000.00
_Owner obtaining own permit(explain):
_Building not owner-occupied
_Other(specify):
OWNERS OBTAINING THEIR OWN PERMIT OR ENTERING INTO CONTRACTS WITH UNREGISTERED
CONTRACTORS OR SUBCONTRACTORS FOR APPLICABLE HOME IMPROVEMENT WORK ARE NOT
ELIGIBLE FOR AND DO NOT HAVE ACCESS TO THE ARBITRATION PROGRAM OR GUARANTY FUND
UNDER M.G.L.Chapter 142A.SUCH OWNERS ALSO ASSUME THE RESPONSIBDdTES FOR ALL WORK
PERFORMED UNDER THE BUILDING PERMIT.SEE NEXT PAGE FOR MORE INFORMATION.
Signed under the penalties of perjury:
I hereby apply for a building permit as the agent of the owner.
qlm I J, • UeNje rM! SOA TAC. o &ffi P X%t&6
Date Contractor Name C " 1 HIC Registration No.
OR:
Notwithstanding the above notice,I hereby apply for a building permit as the owner of the above property:
Date Owner Name and Signature
City of Northampton
% + Northampton,
PHPANTJMT OF BUILDING INSPECTIONS
212 Nein St .t Municipal svildiaug
orthton, M 01060
MANDATORY FOR HOUSES BUILT BEFORE 1945
Property Address: 3g \Nhw �r mt Kyrie., MA jolo a
Contractor
Name: cto!' V4 Son, Inc.
Address: 64 S(uy wpn„l Sf
City, state: (Green}field! MA 01301
Phone: 1413 "��y 369
Property Owner
Name: 2 Indy Wlllhlxy
Address: 36l �iwrierfj we
City, state: p)n(en(f, MA 01061
I, �olge (contractor) attest and affirm that the building I intend to
insulate does not have any open air(knob and tube)wiring in the spaces to be insulated and that I have
provided the property owner with a copy of this affidavit.
Contractor signature \4���1
Date —Y
City of Northampton _
Massachusetts •J' d%f¢
�Q DE3PAa21ffiBT OF BUILDING ZB52'BCTZOBS
212 tisio Sired •tB,nicipal Building
tlorth+mptov, M 01060
Debris Disposal Affidavit
In accordance of the provisions of MGL c 40, S54, I acknowledge that as a condition of the building
permit all debris resulting from the construction activity governed by this Building Permit shall be disposed
of in a properly licensed solid waste disposal facility,as defined by MGL c 111, S 150A.
The debris from construction work being performed at:
3q WI6{,fV4fy We
(Please print house number and street name)
Is to be disposed of at:
QfUfi11¢b�ro -�d� 431 VCrmn Q DIftkioro SUwIe
(Please print name and location of facility)
Or will be disposed of in a dumpster onsite rented or leased from:
(Company Name and Address)
Signature of Pe it Ap lira t o Owner Date
If, for any reason,the debris will not be disposed of as indicated, the Applicant or Owner shall notify the
Building Department as to the location where the debris will be disposed.
The Commonwealth of Massachusetts Pnnt FofM
Department of Industrial Accidents
Office of Investigations
_ I Congress Street,Suite 100
Boston, MA 02114-2017
www.mass.gowdia
Workers' Compensation Insurance Affidavit:Builders/ContractorslElectricians/Plumbers
Applicant Information Please
�Print
(Leei iloty��
Narne(1lusinesvt cr iizmimNnd`ividuai):
t
Address: 6"A ,I1i"VXC6
City/State/Zip: Q,„ 'Q '�- -(e-� {' \�iiiPhonet 6113) 5S `1i lolt
Are you an employer?Check the appropriate box: Type of project(required):
1,® lama employer with 5 4. ❑ I am a general contractor and I
employees(Lull and/or part-lime).* have hired the sub-contractors6. ❑New construction
2.❑ T am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g- ❑ Demolition
workingfor me in an capacity, employees and have workers'
Y9. []Building addition
req workers' comp.insurance comp.a corporal
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their l I.❑Plumbing repairs or additions
myself. [No workers' comp, right of exemption per MGL
12.❑ Roof repairs
insurance required.]t e plo employees.
[ and we have no
employees. [Nc workers 13.®Other 7 y1SV�G. ON
cmnp. insurance required.]
•Any applkam that check,box At must also rill at the secsion bdMv showing their workers'mm ddendinn policy inN eadma.
'nnmeuwna s whn uhrail this amdavet indicting they are doing all work and Wen hire oaaide commowrs must submit a new affidavit i on ming web.
�Gmuncama Wt cheik this hoz must mbaeh,d an additional shc<t showing the name of the sub-emonemrs and slab,whether or min thou:entities have
employmc If u,sub-emoomm i have cugdoyccs,Wev most provide Weir wotken'comp.policy number.
I am an employer that is providing workers'eampeasadon insurance for my employees. Below is thepolicy and job site
information.C �
Insurance Company Name: _
Policy dor Self-ins.L77ii�a#:__ �r Expiration Date:
Job Site Address: \Niilk,tYrfj City/State/Zip: Flowel Mit, 0106a
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 3250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
f do hereb certilyunderthe airs andnal' arperjury
,that the in amunion provided above is true and correct.
Si n m x' Dat
Phone a: ��f 13) 53 f ���6
Oficial use only. Do not write in this area,to be completed by city or town official.
City or Town: PermitfLicense At
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/To”Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Commonwealth of Massachusetts
Division of Professional Uconsum
Board of Buifding R�,�u11ll1ations and Standards
Constructioa,S;; r.Specialty
CSSL-099372 Aires: 02/11/2021
i {
JOSEPH 00Dq E �
ed NAYWOO '
GREENFIELD OL :10
LOIS�d0'��
COTmissioner
Mae ofconsumer&lairs&Busimma Regulauop
ROMEfMPROVEMEMCONTRACTOR' - 9e9ia0atlbnralitl far Individual use only
7YPE:t:poareiici beforetheexNratfondate. Nfoundreturnio:
pggatraton Expiration Office of Consumer Affairs and Business Regulation.
15tK86 07/2612019 10Par&Placa-Sulta5170
vi "ORGE&SONINC faoeton,MA 02118
• JOSEPH GEORGE64 HAYWOOD ST
--1t��Q•"^'-
GREENFIELD MA 01301 Unde��' Not Valid without Signature
OWNER AUTHORIZATION FORM
I, Cindy Wolinsky
(OWWa 9 Neme)
owner of the property located at:
39 Winterberry Lane
(Prope*Addresa)
Florence, MA 01062
(Prop��ertrlyAddress)
hereby authorize Jrf, GbfAe M3 SCA,
(Sabo backr) i
an authorized suboontraetor for RISE Engineering,to act on my behalf to obtain a bu'Jding
permit and to perform work on my property. This form is only valid with a signed contract.
Owner's Signature
Date
RISE Engineering,a Division ofThielsch Engineering,Inc.
60 Shawmut Road Unit 2 1 Canton,MA 020211339-502-633-9
www.RISEengineerina.coin